All Together Better Sunderland

The vanguard and the people it serves

The vanguard in Sunderland has an ambitious vision to transform care by improving the links between its hospitals and community services with those teams working together to provide tailored, better coordinated care for patients at home.

What is changing?

The vanguard is providing a citywide ‘recovery at home’ service offering a rapid response either at home, or close to home, to prevent emergency admissions to hospital. The service also provides short-term support to patients after they go home from hospital.

Community nurses, social workers, GPs and voluntary staff are linked together in five community integrated teams, based around groups of GP practices. These teams are supported by the ‘recovery at home’ service to offer better coordinated care, as well as work together to prevent ill health, particularly for patients most at risk of being admitted to hospital.

GP practices are also working together to deliver enhanced care for patients with long term conditions who could benefit from guidance to improve how they manage their illnesses themselves. Representatives from many of Sunderland’s GP practices – who are often the people closest to those living with long term health conditions – are looking to improve how they provide care, to make sure it is the best possible, while also ensuring it is delivered in the most efficient way.

Key benefits

High quality community and home-based care for people who need it most and who use the most health and social care services in the city

Family or friends looking after vulnerable people will get more support to maintain that level of unpaid care

Staff will be able to influence how well care is provided and gain a better understanding of their colleagues’ roles to improve care overall

Reduction in the number of patients needing urgent help going to hospital, continued reduction in the number of patients being delayed going home and improved patient and staff satisfaction